Written by Caitlín Hastings


Over the past few years, Animorph have been exploring ways of understanding how the cutting-edge capabilities of Extended Reality (XR) may help with addressing medical challenges. We have embarked on an investigation of evidence-based research and are pleased to share our findings with the public.

Two digital spiders viewed through the lenses of a VR headset. The headset appears like a cartoon face of fear.

VR in anxiety; key concepts

As mentioned in our previous instalment, the majority of research in the current literature is focussed on anxiety disorders. This demonstrates the advantage of VR in the recreation of believable ‘real-world’ scenarios and its potential for ecological validity. (1) Due to this, we will focus this piece on anxiety and review the effectiveness of VR in eliciting realistic anxiety responses in treatment and assessment. As anxiety was ranked the ninth largest contributor to global disability by the Global Burden of Disease Study in 2015, (2) VR has a potentially significant contribution to make.

a. Specific phobias

A phobia is defined as a marked and persistent fear cued by the presence or anticipation of specific objects or situations, followed by a desire to avoid these because of high levels of fear and discomfort. (6) Examples include flying phobia, needle phobia, and phobias of animals and heights. This is a widely studied area in VR and VRET has been found to beeffective in addressing phobias, with VRET having a lower drop-out rate than in vivo exposure therapy. (7) Patients are more willing to cooperate as they are not as afraid to confront virtual phobias and maintain a feeling of control over the situation. (8)

b. Social anxiety disorder

Social anxiety disorder (SAD) is a condition marked by anxiety in social conditions which may involve judgement or evaluation by others and a consistent fear of embarrassment or humiliation. These types of situations may be faced and ‘suffered’ through or avoided altogether. (15) Commonly in VR, fear-inducing scenarios are recreated, such as: classrooms, pubs or auditoriums — in the case of public speaking phobia (which we will discuss later in this instalment). Such environments are then populated with avatars which may react to the individual. While there is less research in social phobia and VR than specific phobias, perhaps due to the skill required to develop realistic environments and reactions from avatars, the results do appear to be encouraging.

c. Public speaking phobia

Public speaking phobia (PSP) is a sub-type of social anxiety and is a ‘performance’ related phobia rather than the more generalised social anxiety. This involves debilitating anxiety when speaking in front of crowds (25). It can have a long-term impact on academic, career, and social aspects of a sufferer’s life. It is one of the most common lifetime phobias (21.2%) (26), with sufferers overestimating negative judgement in others and underestimating their own ability. CBT and graduated exposure therapy have been found to be very effective in treatment. However, this requires the use of venues and an audience for an individual to practise, which is difficult to organise and not always economically viable. As avoidance is also a large part of PSP it can also be very difficult for patients to commence with this kind of therapy and there can be high drop-out rates.(27)

d. Panic disorder and agoraphobia

Panic disorder and agoraphobia have been combined here for ease, but while these conditions frequently occur together they may also arise individually with no history of the other. Panic disorder is classified as a sudden rush of anxiety symptoms (palpitations, sweating, digestive discomfort, derealisation, fear of dying, going crazy etc.) which tend to peak within 10 minutes of onset. In the case of panic disorder with agoraphobia (PDA), these anxiety symptoms are provoked by situations where an individual may feel they cannot escape, where escape may be embarrassing, or help may not be available. These situations tend to take place outside of the home where an individual would be on their own such as on public transport, being in crowds or standing in a line or on a bridge. This has the effect that individuals will avoid these situations or will endure them with distress or only with a companion.(31)

e. Generalised anxiety disorder

Generalised anxiety disorder (GAD) is a condition where patients experience daily, persistent, intrusive and excessive worrying about a range of topics, from which they are unable to distract themselves. This can interfere with daily life, affect concentration, and cause irritability, restlessness, fatigue and muscle tension.(36) It is one of the most common disorders noted in primary care, and it is estimated that two-thirds of the patients suffering from GAD do not receive anytreatment for it. Complete remission after 5 years of clinical treatment occurs in only 18–35% of patients and it is associated with other disorders such as depression. (37)

f. Obsessive-compulsive disorder:

Obsessive-compulsive disorder (OCD) is a condition marked by intrusive, unwanted thoughts and ideas, which can be distressing (obsessions), and intentional, repetitive behaviour which can relieve anxiety (compulsions). Examples of common obsessions are contamination and a need for symmetry, and common compulsions are washing, counting and arranging objects in a certain manner (44). Currently, the most common therapy is CBT with exposure and response prevention (ERP), which involves exposure to an obsession-provoking situation and then prevention of the usual compulsion which the patient has learned will alleviate the anxiety associated with their obsession. Thereby teaching the patient to tolerate their distress or cope in a way which will not fuel their symptom cycle. For example, touching something the patient believes to be contaminated and then not washing their hands. (45) However, in recent years it has been posited that metacognitive training (a therapy style which helps patients consider their problematic thinking style) could be as effective. (46)


This second instalment of our literature review illustrated the capacity of VR as an intervention and assessment tool in anxiety disorders. We have discussed the symptomatology of each disorder and how VR can elicit or treat these. We have also outlined the work that is still needed in many of these disorders.


1. Bell, I. H., Nicholas, J., Alvarez-Jimenez, M., Thompson, A., & Valmaggia, L. (2020, June 1). Virtual reality as a clinical tool in mental health research and practice. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366939/

We develop software that enhances human potential. Specialising in Extended Reality for industry training, education, and medical uses.

We develop software that enhances human potential. Specialising in Extended Reality for industry training, education, and medical uses.